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SUBJECTIVE
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Chief Complaint:
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History of Present Illness:
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Medical History:
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Surgical History:
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Current Medications:
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Allergies:
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General Comments:
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OBJECTIVE
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Vital Signs
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Height:
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Weight:
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Temperature
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Heart Rate:
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Blood Pressure
/
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Respiratory Rate:
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02 Saturation:
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General Statements:
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Medications administered intravenously:
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Physical Exam
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General WNL:
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General Abnormal:
• • •
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General Comments:
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Cardiovascular WNL:
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Cardiovascular Abnormal:
• • •
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General Comments:
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Respiratory WNL:
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Respiratory Abnormal:
• • •
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General Comments:
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Gastrointestinal WNL:
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Gastrointestinal Abnormal:
• • •
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General Comments:
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Musculoskeletal WNL:
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Musculoskeletal Abnormal:
• • •
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General Comments:
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Neurological WNL:
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Neurological Abnormal:
• • •
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General Comments:
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Skin WNL:
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Skin Abnormal:
• • •
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General Comments:
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ASSESSMENT
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PLAN
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Procedure Note:
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ICD-10/ CPT CODE:
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Providers Name:
• • •
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